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Spine Tango User’s Manual

Part I: Dictionary of Terms Surgery Version 2011 and Follow up

T. Zweig1, 2 M. Neukamp1, A. Mannion3,5, C. Röder1,5, E. Munting4,5, D. Grob3,5 1. Institute for Evaluative Research in Medicine, University of Bern, Switzerland 2. Orthopedic Department, Kantonsspital Schwyz, Switzerland 3. Spine Unit, Schulthess Klinik Zurich, Switzerland 4. Orthopaedic Department, Clinique Saint Pierre Ottignies, Belgium 5. Spine Tango Committee EuroSpine, the Spine Society of Europe Spine Tango Dictionary of Terms; V. 2.3; April 2012

Spine Tango User’s Manual - Part I: Dictionary of Terms

Surgery 2011 and Follow up

page 2

SURGERY FORM: .............................................................................................................................................. 4

FORMAT.............................................................................................................................................................. 4 LEVEL OF MAIN PATHOLOGY* ............................................................................................................................ 4

ADMISSION/PATHOLOGY .............................................................................................................................. 4

ADMISSION* ....................................................................................................................................................... 4 MAIN PATHOLOGY .............................................................................................................................................. 4 SPECIFICATION OF MAIN PATHOLOGY ................................................................................................................. 5

degenerative Disease ..................................................................................................................................... 5 Type of degeneration ...................................................................................................................................... 6 Deformity ....................................................................................................................................................... 7 Type of deformity ........................................................................................................................................... 7 Type of scoliosis ............................................................................................................................................. 8 Predominant etiology ..................................................................................................................................... 8 (Pathological) Fracture/Trauma ................................................................................................................... 9 Type of (pathological) fracture/trauma .......................................................................................................... 9 Dens fracture type ........................................................................................................................................ 10 C3-L5/S1 AO fracture type .......................................................................................................................... 11 Pathological fracture due to… ..................................................................................................................... 12 Fracture age ................................................................................................................................................. 12 Spondylolisthesis .......................................................................................................................................... 13 Type of spondylolisthesis ............................................................................................................................. 13 Grade of Spondylolisthesis ........................................................................................................................... 14 Inflammation ................................................................................................................................................ 14 Type of inflammation ................................................................................................................................... 14 Criteria for the Classification of Acute Arthritis of Rheumatoid Arthritis (American College of Rheumatology) ............................................................................................................................................. 15 Infection ....................................................................................................................................................... 16 Infection specification .................................................................................................................................. 16 Affected structures........................................................................................................................................ 16 Tumor ........................................................................................................................................................... 16 Type of Tumor .............................................................................................................................................. 16 Localisation .................................................................................................................................................. 17 Specify type of tumor .................................................................................................................................... 17 Repeat surgery ............................................................................................................................................. 17 Type or reason of repeat surgery ................................................................................................................. 17

MOST SEVERELY AFFECTED SEGMENT/ VERTEBRAL BODY ................................................................................ 18 EXTENT OF LESION ........................................................................................................................................... 18 ADDITIONAL PATHOLOGY ................................................................................................................................. 19 NO. OF PREVIOUS SPINE SURGERIES .................................................................................................................. 19

Previous surgery at the same level ............................................................................................................... 19 Previous surgery at the same hospital ......................................................................................................... 19 Previous treatment for main pathology ........................................................................................................ 20

RISK FACTORS .................................................................................................................................................. 20 Presence of flags – for LBP patients ............................................................................................................ 21 Occupational and societal factors, .............................................................................................................. 22 not matters of perception, affect all workers equally: .................................................................................. 22

SURGERY ........................................................................................................................................................... 22

Surgery Date ................................................................................................................................................ 22 SURGICAL PROCEDURE ..................................................................................................................................... 22

Therapeutic goals ......................................................................................................................................... 22 Anterior access ............................................................................................................................................. 23 Posterior access ........................................................................................................................................... 23 Components .................................................................................................................................................. 24 - component description ............................................................................................................................... 24



page 3

Surgeon credentials ...................................................................................................................................... 24 Morbidity State ............................................................................................................................................. 24 Technology ................................................................................................................................................... 26 Operation time ............................................................................................................................................. 27 Prophylaxis .................................................................................................................................................. 27 Blood loss ..................................................................................................................................................... 27 Blood transfusion ......................................................................................................................................... 27 units .............................................................................................................................................................. 27 cell saver ...................................................................................................................................................... 27

SURGICAL MEASURES .................................................................................................................................. 27

DECOMPRESSION .............................................................................................................................................. 27 FUSION ............................................................................................................................................................. 28

Fusion material ............................................................................................................................................ 29 STABILIZATION RIGID ....................................................................................................................................... 30 STABILISATION MOTION PRESERVING ............................................................................................................... 31 PERCUTANEOUS MEASURES .............................................................................................................................. 31 OTHER SURGICAL MEASURES ............................................................................................................................ 32 EXTENT OF SURGERY – INDICATE AS: ............................................................................................................... 32 INTRAOPERATIVE SURGICAL COMPLICATIONS .................................................................................................. 33 SURGICAL MEASURES DURING INDEX SURGERY ................................................................................................ 33 INTRAOPERATIVE GENERAL COMPLICATIONS ................................................................................................... 33

HOSPITAL STAY .............................................................................................................................................. 34

POSTOPERATIVE SURGICAL COMPLICATIONS BEFORE DISCHARGE .................................................................... 34 POSTOPERATIVE GENERAL COMPLICATIONS BEFORE DISCHARGE ..................................................................... 34 RE-INTERVENTION AFTER INDEX SURGERY ....................................................................................................... 35

Hospital stay ................................................................................................................................................ 35 Status of complications ................................................................................................................................ 36 Therapeutic goals upon discharge ............................................................................................................... 36 FU foreseen .................................................................................................................................................. 36 Discharge date ............................................................................................................................................. 36

FOLLOW-UP ..................................................................................................................................................... 36

LEVEL OF INTERVENTION* ................................................................................................................................ 36 FU INTERVAL ................................................................................................................................................... 37 WORK STATUS .................................................................................................................................................. 37 THERAPEUTIC GOALS / MEASURES .................................................................................................................... 37 ACHIEVED ........................................................................................................................................................ 37 PARTIALLY ACHIEVED ...................................................................................................................................... 37 NOT ACHIEVED ................................................................................................................................................. 37 MEDICATION .................................................................................................................................................... 38 OVERALL OUTCOME (EXAMINER) ..................................................................................................................... 38 REHABILITATION .............................................................................................................................................. 38 DECISION .......................................................................................................................................................... 39 COMPLICATIONS* ............................................................................................................................................. 39



page 4

Surgery Form:

Format

minimal Minimal data set, all questions with white

background are excluded.

complete Complete data set, all questions must be

answered.

Level of main pathology*

upper cervical C0-C2

mid/lower cervical C3-C7

cervicothoracic including C7 and T1

thoracic T1-T12

thoracolumbar including T12 and L1

thoraco-lumbo-sacral including T12-lumbar and S1

lumbar L1-L5

lumbo-sacral including L5 and S1

sacral S1-S5

coccyx Os coccyx

*Number of levels in the section has priority:

Pathology from C0-C3: upper cervical

Pathology from C0-C6: mid/lower cervical

Admission/Pathology

Admission*

date of admission* format: Day/Month/Year (DD/MM/YYYY)

*days are counted 0000hrs-2400hrs.

Main pathology single answer

same as stage 1 surgery

(This item is only on the surgery staged 2011 form)

If yes: excludes „specification of main pathology“.



page 5

degenerative disease Pathology without apparent changes other than

those due to aging.

deformity Clinically relevant scoliosis or deviation of sagittal

alignment (more than two segments).

fracture/trauma Fracture or discoligamentous injury as sequelae of

trauma.

pathological fracture Fracture/dislocation due to pathologic conditions of

bone (tumor, osteoporosis etc.).

spondylolisthesis (non

degenerative**)

Vertebral slippage including segmental rotational

displacement.

inflammation Pathology due to rheumatic diseases (e.g. RA,

ankylosing spondylitis, psoriasis etc.).

infection Affection due to microorganisms.

tumor Includes paravertebral soft tissue, bone and

neurogenic tumors of the spine.

repeat surgery Any repeat surgery related to the index treatment/

operation.

other Any other condition that does not fit the

aforementioned pathologies.

**Degenerative spondylolisthesis: includes by definition degenerative changes

and spondylolisthesis. If there is a typical degenerative spondylolisthesis, e.g.

vertebral slippage due to wear and tear of the facets without anatomical changes

of the pars interarticularis, tick “degenerative disease” as main pathology and

specify as “degen. Spondylolisthesis”.

If there is both degenerative spondylolisthesis. and spinal stenosis you can now

choose both since the Type of degeneration is a multiple choice question.

Specification of main

pathology

Specify only in relation to items in the section corresponding to

the chosen “main pathology” .

degenerative Disease



page 6

Type of degeneration

Multiple answers allowed, but only in relation to the main

pathology. These questions serve to improve the definition of

„main pathology“ and to establish subgroups for later more

differentiated identification.

disc herniation/ protrusion Disc material within the borders of the spinal canal either

connected to the disc space (bulging, protrusion) or separated

from it (sequester).

For further classification please tick: “other” and categorise.

central stenosis Central narrowing of the spinal canal due to e.g. hypertrophy of

the yellow ligament (lig. flavum) or bony restriction caused by

enlargement of the facet joint (osteoarthrosis), osteophyte

formation, or degenerative spondylolisthesis



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lateral stenosis Narrowing of the lateral recess of the spinal canal caused by

e.g. disc height decrease,posterolateral disc protrusion or

hypertrophy of the superior articular process.

foraminal stenosis Narrowing of the foramen , intraforaminal stenosis with nerve

root compression.

degenerative disc disease Degeneration of the intervertebral disc.

Disc related pathology, e.g. loss of height, end plate

modifications, intra-discal gas, etc.

(Changing in the disc metabolism may lead to cellular changes,

matrix degradation and structural damages occurring in disc

degeneration).

deformity Deformation of the spine due to degenerative changes

e.g. scoliosis, kyphosis.

Please specify type of deformity!!

degenerative spondylolisthesis Spondylolisthesis due to degenerative changes, e.g. vertebral

slippage due to wear and tear of the facets without anatomical

changes of the pars interarticularis.

Please specify grade of spondylolisthesis!

other instability Hypermobility / loss of stiffness in a motion segment (not

spondylolisthesis) caused by degenerative changes.

myelopathy Gradual loss of nerve function caused by progressive

narrowing of the spinal canal.

facet joint arthrosis Spondylarthrosis, degenerative changes (osteoarthritis) of the

facet joints.

other

Any other condition that does not fit the aforementioned

pathologies.

Deformity

Type of deformity



page 8

scoliosis Coronal spinal curvature of at least 10° with rotation of the

vertebral bodies of unknown origin (Def. Cobb, 1948).

Cobb:

Classifications:

Infantile (0-3 years; IIS)

Juvenile (3-10 years; JIS)

Adolescent (10-18 years; AIS)

Adult (>18 years) onset: primary degenerative or de Novo

Reference: Cobb, J.R.; Outline for the Study of Scoliosis. Instructional Course Lectures,

The American Academy of Orthopaedic Surgeons. Vol. 5, pp.261-275. Ann Arbor, J. W.

Edwards, 19488

kyphosis The Scoliosis research Society proposes to regard 10-40 degrees

as the range for normal kyphosis between the upper endplate T5

and the lower endplate T12.

combined scoliosis and kyphosis

Type of scoliosis

single curve one single curve

double curve two curves:

Major curve: curve with the largest Cobb angle

Minor curves may be compensatory.

Predominant etiology In the case of combined aetiology, indicate the most prominent.



page 9

idiopathic Arising spontaneously or from an obscure or unknown cause.

congenital Failure of formation, failure of segmentation, or mixed.

neuromuscular Neuropathic or myopathic conditions

(e.g sub-classification: Lonstein et al:

Group I: Double thoracic and lumbar curves

Group II: Large lumbar or thoraco-lumbar curves).

degenerative de novo, secondary degenerative

posttraumatic Defective structure due to a trauma or fracture.

M. Scheuermann Scheuermann`s disease (Type I, “classical” Scheuermann`s) is a

thoracic or thoracolumbar hyperkyphosis due to wedged vertebrae

developing during adolescence.

Atypical Scheuermann`s disease (Type II, “lumbar”

Scheuermann`s) affects the lumbar spine and or the

thoracolumbar junction. It is a growth disturbance of the vertebral

bodies without significant wedging causing loss of lumbar lordosis

or mild kyphosis.

other → specify

(Pathological) Fracture/Trauma

In the case of multiple fractures with different types please use

separate forms for each category, if different treatment

modalities are used.

Type of (pathological)

fracture/trauma

condylar C0 fracture of the occipital condyle

Classification: Type I; II und III

C0/C1 dissociation atlanto-occipital dissociation

C1 fracture fracture of C1

C1/2 Instability instability between C1 and C2

C2 dens fracture → specify dens fractures type

C2 other fracture C2 fractures excluding dens fractures

soft tissue injury neck Whiplash injury: post traumatic cervicalgia without

demonstratable tissue lesions by Xrays or MRI.

fracture C3-L5/S1 → specify AO fracture type



page 10

sacrum fracture fracture os sacrum

other → specify

Dens fracture type Specify according to the classification Anderson and d’Alonzo.

Reference: Anderson LD, D`Alonzo RT (1974). Fractures of the odontoid process of the

axis.JBJS-A 56 (8): 1663-1674

I

II

III



page 11

C3-L5/S1 AO fracture type Specify according the AO classification , spine fracture

classification.

A1

A2

A3

B1

B2

B3



page 12

C1

Reference: F.Magerl, M.Aebi, S.D. Gertzbein, J.Harms, S.Nazarian (1994). A

comprehensive classification of thoracic and lumbar injuries. Eur Spine J; 3: 184-201

C2

C3

Pathological fracture due to…

osteoporosis Osteoporosis: progressive systemic skeletal disease with

reduced bone mineral density (BMD).

tumor If ticked: -> go to section tumor and choose “type” and

“localisation”.

other… → specify

Fracture age

fresh fracture < 1 month

old fracture > 1 month



page 13

Spondylolisthesis 1. Dysplastic Spondylolisthesis: Congenital malformation of

the sacrum or neural arch of L5.

2. Isthmic Spondylolisthesis: Stress fracture, elongation, or

acute fracture of the pars.

3. Degenerative Spondylolisthesis: Long-standing arthritic

process of the zygapophyseal joints.

4. Traumatic Spondylolisthesis: Neural arch fracture

excluding the pars region.

5. Pathologic Spondylolisthesis: Bone disease - Paget's,

Metastatic disease, or Osteopetrosis.

6. Iatrogenic Spondylolisthesis: induced as a result of

previous lumbar spine surgery via LAIF or Laminectomy

Type of spondylolisthesis

Reference: Wiltse LL, Rothman LG (1989). Spondylolisthesis:classification, diagnosis,

and natural history. Seminars in Spine Surgery 1(2):78-94.

Type I (congenital, dysplastic) Congenital abnormalities of the upper sacrum or the arch of

L5 permit the olisthesis to occur .

Type II (isthmic) The lesion is in the pars interarticularis. Three subtypes can be

recognized (A. Lytic failure, B. Elongated but intact pars C. Acute

fracture).

Type III (degenerative) *** Long standing intersegmental instability, see comment “main

pathology”

Type IV (traumatic) Fracture in other areas of the bony hook than the pars

Type V (pathological) Localized or generalized bone disease

Type VI (postsurgical) Due to iatrogenic instability; if in adjacent segment, tick “main

pathology “>“Type of degeneration” > adjacent segment and

tick “other”

*** This type of spondylolisthesis is not defined in this section. To define a degenerative

spondylolisthesis, tick main pathology “degenerative disease” and specify as “degenerative

spondylolisthesis”.



page 14

Grade of Spondylolisthesis Meyerding Grading System for classifying slips:

Slips are graded on the basis of the percentage that one vertebral

body has slipped forward over the vertebral body below.

o Grade I slip indicates that 1-24% of the vertebral body has

slipped forward over the body below.

o Grade II indicates a 25-49% slip.

o Grade III indicates a 50-74% slip.

o Grade IV indicates a 75%-99% slip.

If the body completely slips off the body below it is classified as a

Grade V slip, known as spondyloptosis.

Reference: Meyerding HW (1932) Spondylolisthesis. Surg Gynecol Obstet 54: 371-377

Grade 0 lysis of pars without slip

Grade I 0-25% slip

Grade II 25-50% slip

Grade III 50-75% slip

Grade IV > 75% slip

Grade V Spondyloptosis

Inflammation

Type of inflammation



page 15

inflammatory arthritis

(seropositive )

Rheumatoid arthritis (RA) is an autoimmune disorder of unknown

aetiology characterized by symmetric, erosive synovitis and

sometimes multisystem involvement. Most patients exhibit a

chronic fluctuating course of disease that, if left untreated, results

in progressive joint destruction, deformity, disability, and

premature death. Rheumatoid arthritis (RA) most commonly

affects the cervical spine. Tissue destruction causes instability of

the atlantoaxial segment.

Criteria for the Classification of Acute Arthritis of Rheumatoid

Arthritis (American College of Rheumatology)

1. Morning stiffness:

Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement.

2. Arthritis of 3 or more joint areas:

At least 3 joint areas simultaneously have had soft tissue swelling or fluid (not bony overgrowth alone) observed by a physician. The 14 possible areas are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints.

3. Arthritis of hand joints:

At least 1 area swollen (as defined above) in a wrist, MCP, or PIP joint.

4. Symmetric arthritis:

Simultaneous involvement of the same joint areas (as defined in 2) on both sides fo the body (bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry).

5. Rheumatoid nodules:

Subcutaneous nodules, over bony prominences, or extensor surfaces, or in juxtaarticular regions, observed by a physician.

6. Serum rheumatoid factor:

Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of normal control subjects.

7. Radiographic changes:

Radiographic changes typical of rheumatoid arthritis on posteroanterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints (osteoarthritis changes alone do not qualify).



page 16

seronegative arthritis Seronegative arthritis is an umbrella term for various types of

arthritis that have similar symptoms to rheumatoid arthritis but do

not have the rheumatoid factor determining that condition in blood

tests. Seronegative arthritis also tends to have additional

symptoms that rheumatoid arthritis does not. Examples of these

disorders include ankylosing spondylitis, psoriatic arthritis and

reactive arthritis.

ankylosing spondylitis

(M. Bechterew)

Arthritis and osteitis deformans involving the spinal column,

marked by nodular deposits at the edges of the intervertebral

disks, by ossification of the ligaments, and by bony ankylosis of

the intervertebral articulations, resulting in a rounded kyphosis

with rigidity.

other → specify

Infection

Infection specification

pyogenic due to bacteria (not specific)

parasitic due to vermin

tuberculotic tuberculosis

fungal due to fungi

other specify

Affected structures

spondylitis**** infection of the vertebrae

discitis**** infection of the intervertebral disc

epidural space "extradural space" or "peridural space

- space within the spinal canal (bony structures) outside

the dura matter

paravertebral infection infection of the paravertebral soft tissue (muscles etc.)

other specify

****for spondylodiscitis choose spondylitis AND discitis (multiple choice question)

Tumor

Type of Tumor



page 17

primary malignant according to the histologic classification

primary benign according to the histologic classification

secondary malign metastasis

tumor like lesion intermediate

other → specify

Localisation

extraosseous soft tissue Tumor located in the soft tissue, no osseous attendance.

intraosseous

(superficial)

Tumor tissue located superficial in the bone, cortical osseous

structures.

intraosseous (deep) Tumor tissue located deep in the bone, trabecular osseous

structures.

extraosseous (extradural) Tumor tissue located in the spinal canal, extradural without

osseous attendance.

extraoseous (intradural) Tumor tissue located in the spinal canal, intradural without

osseous attendance.

other → specify

Specify type of tumor (p)TNM, histology

Repeat surgery Repeated surgery, because the index surgery did not reach its

technical goals (misplaced screw, insufficient decompression,

non-union…) or clinical goals ( the technical goals are fulfilled

but the symptoms remain, e.g. solid fusion but persistent pain).

Also included are elective repeat surgeries for e.g. metal

removal.

Type or reason of repeat

surgery

hardware removal Removal of Implants: e.g. screws, rods.

non-union Failure of bony consolidation of bridge/union 6 months after

surgery.

instability Exceeded motion in a spinal segment after surgery.

failure to reach

therapeutic goals

Therapeutic goals were not achieved with index surgery.

neurocompression Compression of neural structures with or without neurological

deficits.



page 18

postop infection

superficial

Superficial infection after surgery.

postop infection deep Deep (subfascial) wound/ tissue infection after surgery.

implant malposition Incorrect position of the implant.

implant failure Problem due to an implant e.g. loosening, breakage,.. .

sagittal imbalance Sagittal malalignment of the spine.

adjacent segment

pathology

Progressive (degenerative) changes in the adjacent segment of

the index surgery.

Comments regarding

main pathology:

The section main pathology facilitates grouping of different

pathologies. If combined pathologies of equal clinical

significance are present, or there are special characteristics of

a given pathology, please comment here.

Most severely affected

segment/ vertebral body

segments/vertebral body In segments mark cranial VB (vertebral body)

e.g. for segment L4/5 mark “segment” and “L4”.

In deformity surgery: Use the apex of the main curve as most

severely affected segment/ vertebral body.

Extent of lesion Indicates the number of involved segments (main pathology) nota

bene: not the number of segments treated i.e. operated (e.g.

instrumented).



page 19

Additional pathology This section offers the opportunity to list other relevant

pathologies (multiple answers). However, these pathologies are

not further specified.

Additional pathology must be different from “main pathology”. If

there is a conflict of importance, choose the more severe one

as main pathology.

none

degenerative disease see above

deformity see above

fracture/ Trauma see above

pathological fracture see above

spondylolisthesis (non

degenerative)

see above

inflammation see above

infection see above

tumor see above

repeat surgery see above

other.. -> specify

No. of previous spine surgeries This section allows the documentation of previous

interventions on the spine, at the same level or at different

levels compared with the current procedure.

If “0” is ticked, the following two questions are excluded.

Previous surgery at the same

level single answer

no The addressed level/vertebra was not “touched” before.

yes The same level/vertebra has been addressed before.

partially Applies if the current procedure includes, but is not limited to the

previously operated segment(s).

Previous surgery at the same

hospital

no A previous surgery was done elsewhere.



page 20

yes This patient was operated in your institution already.

partially Applies if at least one but not all the previous interventions have

been performed at the present institution.

Previous treatment for main

pathology multiple answers allowed

none No previous therapy at all.

surgical Surgical treatment already performed because of the same

pathology.

< 3 mon. conservative Conservative treatment of the main pathology less than 3

months.

3-6 mon. conservative Conservative treatment for the main pathology for 3-6 months.

6-12 mon. conservative Conservative treatment for the main pathology for 6-12 months.

>12 mon. conservative Conservative treatment for the main pathology for over 12

months.

Risk factors

BMI Body Mass Index

BMI (kg/m2) = Weight (kg) / Height(m)2

Classification:

Underweight: < 18.5

Normal weight range: >18.5 – 24.99

Overweight : 25 - 29.99

Obese: > 30

current smoker

yes regularly smoking at present

no currently not smoking at all



page 21

Presence of flags – for LBP patients

Flags:

Identifying and managing modifiable risk factors in musculoskeletal disorders.

Classification/ Assessment for the treatment of acute LBP

patients considering psychosocial risk factors. The psychosocial

flags system can e.g. help occupational health practitioners create

suitable rehabilitation plans for employees.

none

red Medical - Biomedical factors:

Serious pathology/ diagnosis, Co-morbidity (i.e. co-existence of

other diseases), Failure of treatment.

yellow Psychosocial or behavioral factors:

Beliefs about pain & injury (e.g. that there is a major underlying

illness/disease, that avoidance of activity will help recovery, that

there is a need for passive physical treatments rather than

active self-management); Psychological distress (e.g.

depression, anger, bereavement, frustration); Unhelpful coping

strategies (e.g. fear of pain and aggravation, catastrophising,

illness behaviour, overreaction to medical problems) ; Perceived

inconsistencies and ambiguities in information about the injury

and its implications; Failure to answer patients’ and families’

worries about the nature of the injury and its implications

orange Abnormal psychological processes:

Distinguishing normal from abnormal psychological processes,

represent the equivalent of red flags for mental health and

psychological problems.

Orange flags can include excessively high levels of distress,

major personality disorders, post-traumatic stress disorders,

drug and alcohol abuse/addictions or clinical depression.

blue Focusing on Socioeconomic/ work factors, perceived features of

work or the social environment:

High demand/low control; unsupportive management style;

Perceived time pressure; Lack of job satisfaction; Work is

physically uncomfortable.



page 22

black Occupational and societal factors,

not matters of perception, affect all workers equally:

Employer’s rehabilitation policy deters gradual reintegration or

mobility; threats to financial security; Qualification criteria for

compensation (e.g. where inactivity is a qualification criterion);

financial incentives; lack of contact with the workplace; duration of

sickness absence

unable to assess

Ref.: Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain, Risk Factors for Long-Term Disability and Work Loss, Accident Compensation Commission, New Zealand, January 1997. Kendall, N. A. S., Burton, A. K., Main, C. J., & Watson, P. J. (2009). Tackling Musculoskeletal Problems – A guide for clinic and workplace: identifying obstacles using the psychosocial flags framework. www.tsoshop.co.uk/flags. London: TSO.

Surgery

Surgery Date Format: Day/Month/Year (DD/MM/YYYY)

Surgical procedure

Therapeutic goals What the surgery should achieve from the surgeon`s

perspective.

axial pain relief Aim of back/neck pain relief after surgery.

peripheral pain relief Aim of leg/arm pain relief after surgery.

functional improvement Aim of functional improvement compared to preoperative

status, e.g. longer walking capacity, mobility achieved by the

intervention, improvement of working ability (home and job),

Improvement of capacity of sports practice.

motor improvement Aim of motoric neurological improvement compared to the

preoperative status, e.g. muscular function of the legs/arms.

sensory improvement Aim of sensory neurological improvement compared to the

preoperative status, e.g. recovery of sensibility.

bladder/ sex. function improvement Aim of improvement of the bladder and sexual function

compared to the preoperative status.

spinal stabilization Aim of stabilization of the spine.



page 23

stop deformity progression Aim of avoiding progression of the spinal deformity.

prophylactic decompression Aim of prophylactic / preventive decompression for avoiding

development of neurocompression.

cosmetic improvement Improvement of the physical appearance of the patient.

diagnostic measures Operation is diagnostic procedure (e.g. biopsy).

other → specify

Anterior access

no anterior access

transoral through oropharyngeal cavity

anterolateral anterior medial approach to the cervical

spine for mainly C3-Th1

Note: anterior approach to the lumbar spine

see retroperitoneal or transperitoneal.

cervicothorac. anterolateral access to pathologies involving cervicothoracic the

junctions

cervicothorac. w/ sternotomy with sternotomie depending on the extent/localisation of

the lesion

thoracotomy thoracotomy to T4-T11

thoracoabdominal Extensive approach opening the thorax and

retroperitoneum by taking down the diaphragm,

gives access to Th10- L2

retroperitoneal anterior approach to L2-S without incision of peritoneum

transperitoneal anterior approach to L2-S through the peritoneal cavity

extreme lateral (e.g. XLIF) lateral, retroperitoneal, trans-psoas approach, ( e.g for XLIF =

extreme lateral interbody fusion)

other… specify

Posterior access

no posterior

midline posterior approach to the cranio-cervical-thoracic-lumbo-

sacral spine

paramedian paramedian incision

posterolateral e.g. costotransversectomie



page 24

percutaneous percutaneous approach for e.g. minimal

invasive surgeries

trans-sacral (e.g. AxiaLIF)

trans-sacral approach (also called

presacral) , used for e.g. AxiaLIF = trans-

sacral axial lumbar interbody fusion (also

called Percutaneous AxiaLIF , anterior para-

axial or paracoccygeal interbody fusion)

other… specify

Components implants (e.g screws, rods, disc prosthesis,…)

with description Activate the component subform for describing article name, article number and supplier.

without description Implants are used but not further specified.

- component description

Supplier name the company

Article Name article description (implant model, size etc. -> can be found

on the Implant sticker.)

Article No Can be found on the Implant sticker

Screws and hooks for example do not have an Article N° but

this field has to be filled out so then put xxx.

Surgeon credentials

specialized spine self indicated, spinal fellowship completed, mayority of current

work focused on spinal disorders

board certif. orthopaedic board certified orthopaedic surgeon

board certified neuro board certified neurosurgeon

orthopaedic in training orthopaedic surgeon in training

neuro in training neurosurgeon in training

other →specify

Morbidity State ASA stands for American Society of Anaesthesiologists. In

1963 the ASA adopted a five step physical status classification

system for assessing a patient before surgery.

Unknown Only if not indicated by the anaesthesiologist .



page 25

ASA 1 (no disturbance) ASA I:

Healthy individual with no systemic disease, undergoing

elective surgery. Patient not at extremes of age. (Note: age

is often ignored as affecting operative risk; however, in

practice, patients at extreme of age are often thought to

represent increased risk).

Examples:

- Fit patient with inguinal hernia.

- Fibroid uterus in otherwise healthy woman.

ASA 2 (mild/moderate) ASA II:

Individual with one system, well controlled disease.

Disease does not affect daily activities. Other anesthetic

risk factors, including mild obesity, alcoholism, and smoking

can be incorporated at this level.

Examples:

- Non-limiting or only slightly limiting organic heart disease.

- Mild diabetes, essential hypertension, or anemia.

ASA 3 (severe) ASA III:

Individual with multiple system disease or well-

controlled major system disease. Disease status limits

daily activity. However, there is no immediate danger of

death from any individual disease.

Examples:

- Severely limiting organic heart disease.

- Severe diabetes with vascular complications.

- Moderate to severe degrees of pulmonary insufficiency.

- Angina pectoris or healed myocardial infarction



page 26

ASA 4 (life threatening) ASA IV:

Individual with severe incapacitating disease. Normally,

disease stage is poorly controlled or end stage. Danger of

death due to organ failure is always present.

Examples:

- Organic heart disease showing marked signs of cardiac

insufficiency, persistent anginal syndrome, or active

myocarditis.

- Advanced degrees of pulmonary, hepatic, renal, or

endocrine insufficiency.

ASA 5 (moribund) ASA V:

Patient who is in imminent danger of death. Operation

deemed to be a last resort attempt at preserving life. Patient

not expected to live through the next 24 hours. In some

cases, the patient may be relatively healthy prior to

catastrophic event which led to current medical condition.

Examples:

- Burst abdominal aneurysma with profound shock.

- Major cerebral trauma with rapidly increasing intracranial

pressure.

- Massive pulmonary embolus

(Note: most of these patients require operations as a

resuscitative measure with little, if any, anesthesia.)

Reference: Composite from different editions of the "Textbook of Surgery"

(Sabiston, David C., Textbook of surgery. Philadelphia: W.B. Saunders Company).

Technology

conventional Conventional open surgery without any of the assistive

devices mentioned below.

MISS/LISS MISS: minimally invasive spine surgery

LISS: less invasive spine surgery

loops Surgeon uses loops.

endoscope Surgeon uses endoscope.



page 27

CASS computer assisted surgery

microscope Surgeon uses microscope.

neuromonitoring Intraoperative neurophysiological monitoring (IONM) or

intraoperative neuromonitoring to monitor the functional

integrity of certain neural structures during surgery.

other… specify

Operation time Indicate the duration of surgery (skin to

skin)

Prophylaxis

none

infection antibiotic prophylaxis

thrombembolism thromboembolism prophylaxis: pharmacological and/or compression hosiery

ossification ossification prophylaxis, e.g. with NSAIDs

Blood loss Indicate the amount of blood lost.

Blood transfusion Indicate the number of transfused units

(autologous and allogeneic).

Also indicate if a cell-saver was used.

units Specify the number of units.

cell saver The cell saver collects blood from the surgical field to a machine which separates the red blood cells from detritus, washes and concentrates the red blood cells to be reinfused into the patient.

Surgical measures

Decompression Indicate the anatomical location where decompression is

performed (not the route of access).

none



page 28

anterior

decompression in front of the dural sack,

whatever the approach (anterior or

posterior):

removal of disk or endplate osteophytes

posterior decompression about the posterior aspect

of the dural sack:

facet joint osteophytes, ligamentum flavum,

synovial cyst

Specification:

discectomy partial/total excision of an intervertebral disk partially and total

vertebrectomy partial partial resection of the vertebra

vertebrectomy full complete / full resection of the vertebra

osteotomy resection of bone

laminotomy partial resection resp. opening the spinal canal through the

lamina

hemi-laminectomy removal of one side of the vertebral lamina

laminectomy Removal of the posterior arch of a vertebra

facet joint resection partial partial resection of the facet joints

facet joint resection full complete resection of the facet joint

sequestrectomy excision of a sequester

Flavectomy removal of the lig. flavum

flavotomy opening of the lig. flavum

foraminotomy bone resection / widening of the foraminae

laminoplasty The laminae are reattached to preserve lumbar stability.

uncoforaminotomy anterior cervical foraminotomy

other… specify

Fusion Indicate the anatomical location where the structures are

prepared for fusion (not the route of access) (e.g. TLIF/PLIF

with pedicle fixation: anterior and posterior).

none

anterior Implies an anterior interbody fusion

whatever the approach : anterior or

posterior.

posterior Implies a posterior fusion whatever the

approach : anterior or posterior



page 29

Specification:

none

interbody fusion A-IF Interbody Fusion A-IF

Anterior interbody fusion of adjacent or distant vertebrae through an anterior approach

A-IF= anterior cervical/thoracic/lumbar interbody fusion (location defined by Level of intervention question)

interbody fusion PLIF anterior interbody fusion of adjacent or distant vertebrae

through a posterior approach

PLIF= posterior lumbar interbody fusion

interbody fusion TLIF anterior interbody fusion of adjacent or distant vertebrae

through a posterior approach.

TLIF = transforaminal lumbar interbody fusion

interbody fusion XLIF anterior interbody fusion of adjacent or distant vertebrae

through a far lateral approach)

XLIF = Extreme lateral interbody fusion

other interbody fusion If anterior interbody fusion types like A-IF, PLIF, TLIF and XLIF

do not apply, e.g. with AxiaLIF.

posterolateral fusion posterolateral attachment of fusion material

posterior fusion posterior attachment of fusion material

other... specify

Fusion material Substance that is intended to contribute to future bony union

(e.g. BMP)

none

autol. bone harvested fusion material: autologous bone, harvested

in extra location

autol. bone locally produced fusion material: autologous bone locally

produced during operation, e.g. via spinal

decompression

allog. bone fusion material: allogeneic bone

bone subst. fusion material: bone substitute

cement fusion material: cement

BMP or similar bone morphogenetic protein, other growth

factors

other… specify



page 30

Stabilization rigid Anatomical location, where implants are placed (not route of

access) according to the 3-column model (anterior and

middle column count as anterior, posterior column counts as

posterior)

anterior Use of device for stabilizing the anterior/

middle spinal column in a rigid way, e.g.

interbody cage

posterior Use of device for stabilizing the posterior

spinal column in a rigid way, e.g. pedicle

screws with rod

Specification:

interbody stabil. with cage Cage implantation between two adjacent

vertebrae (through an anterior OR posterior

approach). Usually regarded as anterior

rigid stabilization/ anterior and middle

column).

interbody stabil. with auto-/

allograft

Stabilization between adjacent vertebrae with autogeneic or

allogeneic bone graft. Usually regarded as anterior rigid

stabilization.

Vertebral body replacement

with auto-/ allograft

Vertebral body replacement by an auto- or allograft with total or

partial vertebral resection. Usually regarded as anterior rigid

stabilization.

vertebral body replacement by

cage

Cage implantation as vertebral body replacement with total or

partial vertebral resection. Usually regarded as anterior rigid

stabilization.



page 31

plates stabilisation with plates

Usually regarded as anterior rigid stabilization whereby plate

can be attached at anterior or lateral aspect of vertebral body.

pedicle screws with rod Stabilisation with pedicle screws with rod. A posterior form of

spinal stabilization.

facet screws Means of posterior ??? osteosynthesis specific to the lumbar

spine. The screw (usually two per level) crosses the facet joint

????

transarticular screws C1-C2 Stabilisation with transarticular screws through the C2-C1 joint

realized by posterior approach

laminar hooks with rod Stabilisation with laminar hooks with rod. A posterior form of


pedicle hooks with rod Stabilisation with pedicle hooks with rod. A posterior form of


lateral mass screw with rod Stabilisation with lateral mass screw with rod. A posterior form

of cervical spinal stabilization.

odontoid screw Anterior cervical spinal stabilisation with odontoid screw

laminar screws Translaminar facet screw fixation (TLFS). A posterior form of


other… → specify

Stabilisation motion preserving Any measure aiming to preserve some motion of the adressed

area.

none

anterior The total disc replacement is a typical anterior motion

preserving stabilization.

posterior Dynesis or interspinous spacers are examples for posterior

motion preserving stabilization devices.

Specification:

disc replacement motion preserving stabilization by disc replacement (disc

arthroplasty)

interspinous spacer interspinous process implants

dynamic stabilization system motion preserving stabilization by posterior dynamic technique

other… specify

Percutaneous measures



page 32

none

posterior -> specify

facet block injection of anesthetic into the facet joints

root block Nerve root block performed (under image intensifier control)

allowing a direct application of an anti-inflammatory/analgesic

agent to the target nerve root.

discography intradiscal injection, provoking discogenic pain

vertebroplasty Injection of cement into the fractured vertebral body for internal

stabilization.

kyphoplasty Similar to vertebroplasty in the use of cement for internal

stabilization of a vertebral compression fracture but by injecting

the cement into a intervertebral cavity created by the insertion

and inflation of a balloon.

epidural injections injection of e.g. anaesthetic, corticosteroids into the epidural

space

other… specify

Other surgical measures Any other surgical procedure not matching the surgical

terminology matrix given above.

no

yes

Extent of surgery – indicate as: Cranio-caudal spinal range treated i.e. operated (e.g.

instrumented or decompressed)

from (first row)

to (second row)

for non-contiguous segments (i.e. L1/2 and L4/5 in one surgery) document the extent of surgery .from the most cranial to the most caudal segment, even if there are healthy ones in between.

segments/ vertebral body

from First row:

Indicate the most cranial segment or vertebral body of the

operation.

to Second row:

Indicate the most caudal segment or vertebral body of the

operation.



page 33

Intraoperative surgical complications

surgical complications occurring during the surgery

none

nerve root damage iatrogenic nerve root damage due to surgery

spinal cord damage iatrogenic spinal cord damage due to surgery

dura lesion iatrogenic damage of the dura with liquor emission

vascular injury iatrogenic damage of a vessel

fx spinal structures fx = fracture

iatrogenic fracture of osseous spinal structures, e.g. pedicle or

vertebral body

other →specify

not documented Complications unknown or unwillingness to record them.

Surgical measures during index surgery

measures taken because of complications occurred during

surgery

none

suture/ glue suture or glueing of e.g. a dura lesion

other →specify

Intraoperative general complications

general complications occurring during the surgery

none

anaesthesiological complications during operation due to anaesthesia / narcosis

Cardiovascular cardiovascular complications during operation but not

necessarily due to surgical intervention

Pulmonary pulmonary complications during operation but not necessarily

due to surgical intervention

thrombembolism thrombosis / embolism

Intraoperative clot formation (thrombus) in a blood vessel that

breaks loose and is carried by the blood stream to plug another

vessel (e.g. in the leg, kidneys, lungs (pulmonary embolism),

brain (stroke) or gastrointestinal tract).

death death during the operation

other →specify




page 34

Hospital stay

Postoperative surgical

complications before discharge

Complications occured after index surgery but during

hospitalisation.

Refers exclusively to complications that occur during the

hospital stay of the recorded surgery

none No complication occurred

epidural hematoma bleeding hematoma outside dural sack but inside bony spinal

canal

other hematoma hematoma in other localization, but related to surgery

radiculopathy affection of nerve root which can lead to radicular pain,

weakness, numbness, or difficulty controlling specific

muscles

CSF leak/ pseudomeningocele cerebrospinal fluid leak, fistula

motor dysfunction motoric/ muscle dysfunction, new or worse compared to

preoperative

sensory dysfunction sensory dysfunction, new or worse compared to

preoperative

bowel / bladder dysfunction bowel or bladder dysfunction due to iatrogenic damage,

new or worse compared to preoperative

wound infection superficial postoperative superficial wound infection

wound infection deep postoperative deep / subfascial wound infection

implant malposition incorrect positioning of the implant

implant failure failure of the implant e.g. breakage

wrong level surgery on the wrong level, not on level of main pathology

other →specify


Postoperative general

complications before discharge

Complications appeared after index surgery but during

hospitalisation.

Refers exclusively to complications that occur during the

hospital stay of the recorded surgery

none



page 35

anaesthesiological postoperative complications related to anaesthesia /

narcosis

e.g.: sore throat or swallowing problems after intubation

cardiovascular Cardiovascular postoperative complications

e.g.: heart rhythm disturbances after index surgery

pulmonary Pulmonary postoperative complications

e.g.: pulmonary edema with dyspnea after index surgery

thrombembolism thrombosis / embolism

Clot formation (thrombus) in a blood vessel during

hospitalization that breaks loose and is carried by the blood

stream to plug another vessel (e.g. in the leg, kidneys, lungs

(pulmonary embolism), brain (stroke) or gastrointestinal

tract).

death death after surgery, related or unrelated to the intervention.

other… specify

Re-intervention after index

surgery

Second or multiple Interventions caused by complications,

performed after index surgery, not planned in advance,

during the same hospitalization.

none

hematoma evacuation surgical evacuation of hematoma

suture / glue suture or glueing of any structure that was not anatomically

restored or became apparently insufficient after surgery

hardware removal metal removal because of a complication

hardware re-implantation re-implantation after metal removal or implant failure

abscess drainage abscess drainage because of postoperative infection

(further) decompression expanded enlarged decompression because initial

decompression was insufficient

other → specify

not documented Details of re-intervention unknown or unwillingness to record

them.

Hospital stay

uneventful no special events other than during a routine hospitalisation

ICU > 2 days intensive care unit stay longer than 2 days

extended stay extended stay longer than normal with regard to the

respective intervention and because of complications



page 36

Status of complications status of complications at the time of discharge

resolved Complications are completely or almost completely resolved.

No more obvious restrictions from complications.

improved Complications have improved but are still obvious and may

still restrict patient function or well-being.

persisting Complications remain with same severity as when they

occurred.

Therapeutic goals upon

discharge

achievement of the therapeutic goals that were set

preoperatively and recorded in the surgery section (see

above)

achieved The surgical goals are already completely or almost

completely achieved at the time of discharge.

partially achieved The surgical goals are only partially achieved at the time of

discharge and a further improvement is needed in order to

consider them as achieved.

not achieved The surgical goals are definitely not yet achieved at the time

of discharge and a further improvement is needed in order to

consider them as at least partially or even achieved.

FU foreseen Indicates that one or several followups in the institution were

the surgery was performed are foreseen/ planned.

Discharge date format: Day/Month/Year (DD/MM/YYYY)

Follow-up

Level of intervention*

upper cervical C0-C2

mid/lower cervical C3-C7

cervicothoracic Including C7 and T1

thoracic T1-T12

thoracolumbar Including T12 and L1

thoraco-lumbo-sacral Including T12-lumbar and S1



page 37

lumbar L1-L5

lumbosacral Including L5 and S1

sacral S1-S5

coccyx Os coccyx

*Number of levels in the section has priority:

Fixation from C0-C3: upper cervical

Fixation from C0-C6: mid/lower cervical

FU interval Tick the interval closest to the respective date or use

the “other” answer option and specify followup interval.

Work status

not at work since op no work activity at all since surgery

started partially same job any amount of activity in old job (%)

fully reintegrated same professional situation as before surgery

resumed work, but quit again failed attempt to go back to work, even if part time

resumed work, different job successful attempt to go back to work but in a different position

has been dismissed job loss, no new occupation yet

retired since OP includes both age and disability pension

retired before OP includes both age and disability pension

housewife full-time homemaker

child/student not yet in professional or home based work situation

other → specify

Therapeutic goals / measures

Achieved

Partially achieved

Not achieved

Tick all that apply referring to the therapeutic goals

chosen in the surgery form.

Has to reflect the subjective impression of the

surgeon, i.e the achievement of the goals as they were

“negotiated” preoperatively .

For description see surgery form above



page 38

Medication Tick all that apply, take note of WHO scheme of pain

treatment.

WHO Scheme

Level 1 Step 1: MILD PAIN Paracetamol , NSAIDS (and adjuvants if needed) adjuvants include: if nerve pain: tricyclic antidepressants / anti convulsants, steroids

Level 2 Step 2: MILD TO MODERATE PAIN Mild acting opioids + Step 1 Non-opoids (and adjuvants if needed) mild acting opioids: codeine, dihydrocodeine, dextropropoxyphene

Level 3 Step 3: MODERATE TO SEVERE PAIN Stronger opioids + Step 1 non-opioids (and adjuvants if needed) Stronger opioids: Morphine, dimorphine, fentanyl, hydromorphine

Overall outcome (examiner) Reflects the general impression of the outcome from

the physician`s perspective.

Rehabilitation

none no organized and structured postop treatment

home based individually practiced exercises at home, as initially shown by a

therapist in hospital

outpatient/inpatient structured and monitored rehabilitation program



page 39

Decision

no further follow-up Patient discharged from care and supervision by treatment

center.

further follow-up Appointment made for further followup at treating center.

revision foreseen Surgical revision decided at the time of followup visit/

examination.

other primary intervention

foreseen

Additional spinal intervention decided that is not related to

complications or (insufficient) outcome of index intervention

but to a different main pathology or same main pathology at

different level.

Complications*

*Complications to be indicated in relation to untoward events arising since the last recorded Tango form.

Examples:

Infection after discharge: will be recorded only at first FU examination.

Implant loosening will be reported at first FU when diagnosis is made.

The complication is either a new event or a remaining sequela from a previously mentioned

complication That sequela may disappear at a later follow-up.

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